Ronald B. Kuppersmith

Robotic thyroid surgery: An initial experience with North American patients†

To review the initial experience of gasless transaxillary robot‐assisted endoscopic thyroid surgery in a series of patients and describe modifications of the technique for the North American patients, selection criteria, and other issues related to this technology.

Robotic Thyroidectomy: A Framework for New Technology Assessment and Safe Implementation

Robotic thyroidectomy is a new approach to thyroid surgery that offers the benefit of eliminating the anterior neck incision utilized in traditional approaches. Although no level I evidence exists to strongly support a robotic approach to thyroid surgery, initial non-randomized reports of robotic surgical approaches, in a variety of surgical specialty areas such as cardiothoracic, urologic, gynecologic and head and neck surgery suggest possible advantages of robot assisted techniques. These include platform and instrument stability, tremor reduction, articulating end effectors, three-dimensional, magnified imaging, and improved surgeon ergonomics. Potential negatives associated with robotic surgery include its expense, the lack of haptic feedback, instrument limitations, and the implicit learning curve. Robotic thyroidectomy introduces new potential risks, not typically associated with thyroid surgery. These risks are related to a new approach to the surrounding anatomy and are also associated with the learning curve. The introduction of new technology to any surgery mandates a rational framework for initial assessment and safe implementation. A New Technology Task Force was convened to draft guiding principles which may serve as a framework for the safe implementation of emerging technologies in thyroid surgery. This document suggests initial minimum steps that surgeons should consider during initial implementation of robotic thyroidectomy.

The use of intensity modulated radiotherapy for the treatment of extensive and recurrent juvenile angiofibroma.

These case series are presented to describe the application and advantages of intensity modulated radiotherapy (IMRT) for the treatment of extensive and/or recurrent juvenile angiofibroma. Two patients were diagnosed with recurrence at 11 and 13 months postoperatively, and one was surgically unresectable. The affected areas included the base of skull, cavernous sinus, pterygopalatine fossa, infratemporal fossa, posterior orbit and nasopharynx. Highly conformal IMRT was delivered with limited radiation doses to the optic nerves, optic chiasm, brainstem, brain, spinal cord, lens, retina, mandible, and parotid. The total dose delivered to the tumor varied from 3400 to 4500 cGy. The tumor shrunk radiographically in all three cases and there was no endoscopic evidence of disease in two cases at 15 months and 40 months. There was no acute toxicity. Late toxicity was limited to one episode of epistaxis and persistent rhinitis in one patient. In conclusion, IMRT provides several advantages over conventional radiotherapy in the treatment of recurrent juvenile angiofibroma.

Robotic Thyroidectomy: Operative Technique Using a Transaxillary Endoscopic Approach Without CO2 Insufflation

In the last 20 years, there has been a significant increase in the diagnosis of benign and malignant thyroid tumors. With improved ultrasound technology and better access to sonographic imaging, many tumors are identified at earlier stages. Consequently, there has been an evolution in surgical technique, moving toward minimally invasive approaches. This article describes the technique of robotic thyroidectomy via transaxillary endoscopic approach without CO(2) insufflation.

Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy.

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.

VOCAL CORD PARALYSIS IN INFANTS AND CHILDREN

Vocal cord paralysis is the second most common cause of neonatal stridor. Recognition of laryngeal paralysis warrants further evaluation for an underlying etiology as it is frequently a manifestation of a multisystem anomaly. Initial intervention must concentrate on airway stabilization and treatment of any underlying conditions. Management strategies should be individualized and focus on maintenance of a safe and stable airway, acquisition of intelligible speech, and deglutition without aspiration.

Robotic axillary thyroidectomy: Multi-institutional clinical experience with the daVinci

Multi-Institutional Clinical Experience with the daVinci Melanie Seybt, MD1, Ronald B. Kuppersmith, MD2, F. Christopher Holsinger, MD3 , David J. Terris, MD1 1Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta, Georgia 2 The Texas Institute for Thyroid and Parathyroid Surgery, College Station, Texas 3Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, Texas

Advanced approaches for thyroid surgery

Over the past several years, new surgical approaches to the thyroid have been described, and efforts to further refine thyroid surgery continue. These new approaches can be classified by the anatomic location that access is obtained and whether CO2 insufflation is necessary for the procedure to be performed. While these new approaches provide the potential for exciting innovation, more work should be done to refine some of these techniques and study the implications of adopting them from the perspective of patient outcomes and cost.

USE OF AN INTERNET-BASED JOURNAL CLUB

The on-line journal club is a useful example of the educational advantages created by the combination of current Internet technology with traditional journal club methods.

American Thyroid Association's central neck dissection terminology and classification for thyroid cancer consensus statement.

The American Thyroid Association recently published a consensus statement on central neck dissection terminology and classification for thyroid cancer. The American Academy of Otolaryngology–Head and Neck Surgery had representation in this multidisciplinary effort, which also included endocrinologists and general endocrine surgeons. This important statement will help surgeons standardize terminology and clarify the intent (elective vs therapeutic) and extent (unilateral vs bilateral) of central neck dissection in operative reports and publications.